Failure to Use Required Two-Person Assist and Prevent Bed-Related Injury During Repositioning
Penalty
Summary
The deficiency involves a failure to ensure the environment was free from accident hazards and that adequate supervision and assistance were provided during resident repositioning. A Licensed Vocational Nurse (LVN 1) repositioned a resident who, per the Minimum Data Set (MDS), was dependent on staff and required the assistance of two or more helpers to roll from side to side. Despite knowing the resident was a two-person assist, LVN 1 proceeded to reposition the resident alone because other staff were busy. The facility’s policy on positioning and moving residents required staff to assess the resident’s physical abilities, mobility limitations, strength, awareness, and ability to follow directions, and to use maximum precautions and obtain assistance as needed, but this was not followed. The resident involved had severe cognitive impairment due to dementia and Alzheimer’s disease and was documented as dependent on staff for rolling left to right, with functional limitations in range of motion in both upper and lower extremities. On the evening of the incident, CNAs caring for the resident, who also stated the resident required a two-person assist, noticed the resident’s right knee was bending abnormally and informed LVN 1. During LVN 1’s rounds, she found the resident at the edge of the right side of the bed with the right foot hitting the bed’s footboard. To prevent a fall, LVN 1 decided to reposition the resident without waiting for assistance, using a draw sheet to pull the resident up while both legs were straight and the right leg crossed over the left. As LVN 1 turned the resident toward the left side of the bed, the resident moved her legs and the right knee struck an exposed portion of the bed frame at the bottom of the bed where the mattress did not fully cover the frame. LVN 1 observed the resident grimacing and moaning, with redness, swelling, and tenderness of the right knee. Subsequent assessment and imaging showed an acute right distal femur fracture. The resident was transferred to a general acute care hospital, where the fracture, associated swelling, deformity of the distal thigh, and need for immobilization, pain control, and monitoring for complications were documented. An orthopedic consultation later noted the injury was likely related to malunion and that surgery was not recommended due to the resident’s dementia and non-ambulatory status.
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